Best evidence for managing cutaneous immune-related adverse events in cancer: A summary from Chinese and English literature - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Asia Pac J Oncol Nurs . 2026 Mar 25;13:100943. doi: 10.1016/j.apjon.2026.100943 Search in PMC Search in PubMed View in NLM Catalog Add to search Best evidence for managing cutaneous immune-related adverse events in cancer: A summary from Chinese and English literature Zhenzhen Su Zhenzhen Su a Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Nursing Department, Peking University Cancer Hospital & Institute, Beijing, China Find articles by Zhenzhen Su a , Shuyu Han Shuyu Han b Peking University School of Nursing, Beijing, China Find articles by Shuyu Han b , Liyan Zhang Liyan Zhang c Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Oncology, Peking University Cancer Hospital & Institute, Beijing, China Find articles by Liyan Zhang c, ⁎ , Xuemin Lian Xuemin Lian d Tianjin Medical University General Hospital, Department of Health and Medical, Tianjin, China Find articles by Xuemin Lian d , Yixuan Wang Yixuan Wang b Peking University School of Nursing, Beijing, China Find articles by Yixuan Wang b , Dan Liu Dan Liu b Peking University School of Nursing, Beijing, China Find articles by Dan Liu b Author information Article notes Copyright and License information a Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Nursing Department, Peking University Cancer Hospital & Institute, Beijing, China b Peking University School of Nursing, Beijing, China c Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Department of Gastrointestinal Oncology, Peking University Cancer Hospital & Institute, Beijing, China d Tianjin Medical University General Hospital, Department of Health and Medical, Tianjin, China ⁎ Corresponding author. [email protected] Received 2025 Nov 10; Accepted 2026 Mar 23; Collection date 2026 Dec. © 2026 The Author(s) This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). PMC Copyright notice PMCID: PMC13092064 PMID: 42011381 Abstract Objective This study aims to summarize the best evidence for cutaneous immune-related adverse events (cirAEs) nursing in cancer patients, which provides theoretical support for standardizing the preventive, assessment, grading, nursing interventions, and follow-up of various cirAEs. Methods Guided by the 6S evidence hierarchy, a comprehensive search was conducted in Chinese and English databases including UpToDate, BMJ Best Practice, Cochrane Library, PubMed, Embase, CINAHL, SinoMed, CNKI, Wanfang, and VIP databases, as well as 19 guideline or academic websites, retrieving evidence from the database's inception to November 5th, 2025. Two reviewers independently screened and appraised eligible publications, including guidelines, evidence summaries, clinical decisions, expert consensuses, and systematic reviews. Results A total of 24 Chinese and English articles were included, comprising 7 guidelines, 3 systematic reviews, 9 expert consensuses, 2 clinical decisions, and 3 evidence summaries. We identified 25 best-evidence recommendations across five key dimensions: prevention, assessment, grading, nursing interventions, health education, and follow-up. Following expert evaluation based on the FAME framework, 17 recommendations were graded as strong and 8 as weak. Conclusions This study consolidates evidence-based recommendations from Chinese and English literature for cirAEs nursing management. Clinical implementation should integrate patient preferences, contextual factors, and potential barriers to evidence application. Ongoing assessment of emerging research is warranted. Systematic review registration This study was registered at the Fudan University Centre for Evidence-based Nursing (Registration No. ES20259226). Keywords: Cancer, Skin, Immunotherapy, Cutaneous immune-related adverse events, Evidence-based nursing Introduction In recent years, immunotherapy—particularly immune checkpoint inhibitors (ICIs)—has emerged as a first-line treatment for various cancers. 1 ICIs, including programmed cell death-1 (PD-1) and programmed death-ligand 1 (PD-L1) inhibitors, as well as cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) inhibitors, have demonstrated significant clinical benefits in treating cancers such as melanoma, bladder cancer, cervical cancer, and liver cancer. 2 , 3 However, while ICIs enhance antitumor immunity, they can also disrupt normal immune tolerance, leading to immune-related adverse events (irAEs). 4 The incidence of irAEs is estimated to be as high as 80%, affecting multiple organ systems, including the skin, gastrointestinal tract, lungs, and bones. These toxicities impact more than 50% of treated patients and can significantly reduce the survival benefits of immunotherapy. 5 Cutaneous immune-related adverse events (cirAEs) are among the earliest and most prevalent irAEs, with an incidence ranging from 30% to 90% and a median onset of approximately 5 weeks. 6 , 7 In some cases, cirAEs appear within the first week of treatment. Common manifestations include maculopapular rash, lichenoid dermatitis, psoriasis, pruritus, and mucosal lesions, which may present individually or in combination. 8 , 9 The diverse clinical presentations of cirAEs pose challenges for early and accurate diagnosis. 10 While more than 90% of cirAEs reported in clinical trials are mild to moderate, their recurrent nature and involvement of visible areas (e.g., face and limbs) can significantly affect patients’ psychological well-being, physical comfort, and daily functioning, ultimately reducing their quality of life. 11 , 12 Inadequate management can lead to disease progression, treatment interruptions, and complications from prolonged corticosteroid use. 13 Although severe or life-threatening cirAEs are rare (occurring in < 1% of cases), when they do occur—such as toxic epidermal necrolysis (TEN)—the associated mortality rate can be as high as 10%–50%. 14 Given these risks, comprehensive and effective nursing care is essential to improving symptom management, enhancing quality of life. By effectively mitigating cirAEs, such care also contributes to maintaining planned treatment schedules and reducing the need for dose modifications or interruptions. Clinical nurses must be equipped with the knowledge and skills to identify high-risk patients, assess cirAEs severity, and implement appropriate interventions, to improve patients' quality of life and reinforce their treatment adherence during cancer treatment. Despite the growing recognition of cirAEs, research on nursing strategies remains limited. Most studies are small-scale, single-center investigations with incomplete nursing protocols , focusing solely on one aspect of care (such as psychological care). 15 , 16 While these studies demonstrated some symptom improvement, they did not fully address symptom prevention, quality of life, or long-term follow-up. Some experimental studies have proposed various nursing measures for cirAEs, but most focus on isolated aspects, thereby restricting nursing effectiveness. 17 , 18 , 19 For instance, Liu et al. conducted a trial involving 100 cancer patients treated with ICIs and found that adequate health education significantly reduced cirAEs incidence (2% vs. 8%, P < 0.05). 17 However, the study focused solely on prevention and did not assess symptom management after cirAEs developed, making it difficult to assess symptom alleviation due to cirAEs nursing. Therefore, there is an urgent clinical need for comprehensive and effective intervention protocols for cirAEs nursing to guide clinical practice. Furthermore, while several international and domestic guidelines, 20 , 21 , 22 , 23 expert consensuses, 24 , 25 and evidence summaries have been published, 26 , 27 , 28 their recommendations are often fragmented, sometimes inconsistent, and predominantly centered on treatment modalities rather than nursing-specific interventions. To sum up, existing evidence is narrowly focused on limited symptoms, guidelines are fragmented and inconsistent, and a comprehensive nursing-specific protocol is lacking. Given these gaps, our study systematically integrates the best available nursing evidence for cirAEs across all cancer types, incorporates the principles of cirAEs management, 29 and provides a comprehensive summary of the prevention, assessment, grading, nursing interventions, and follow-up of various cirAEs, with the aim of providing guidance and recommendations for clinical oncology nurses. Methods This evidence summary followed the evidence summary reporting specifications of Fudan University Center for Evidence-based Nursing, which were based on the methodological process for the summary of the evidence produced by the Joanna Briggs Institute (JBI). 30 This study was enrolled in Fudan University Centre for Evidence-Based Nursing (Registration No. ES20259226). This evidence summary follows the reporting standards set by the Evidence-Based Nursing Center of Fudan University. Formulation of problem The evidence-based question was developed using the PIPOST model, proposed by the Evidence-Based Nursing Center of Fudan University. 31 The model defines the following elements: (i) Population (P): Adults diagnosed with cancer who are currently receiving or have previously received ICIs. (ii) Intervention (I): Nursing-related aspects of cirAEs, including health education, assessment and monitoring, prevention, symptom grading, symptom management, and follow-up. (iii) Professional (P): Clinical or community-based nursing professionals. (iv) Outcome (O): Primary outcomes are cirAE-related patient outcomes, including the incidence of cirAEs after nursing interventions, symptom remission/alleviation, psychological and social impact, and cirAE-related quality of life. (v) Setting (S): Outpatient clinics, hospital wards, and community healthcare settings. (vi) Type of Evidence (T): Guidelines, evidence summaries, clinical decision-making resources, expert consensuses, and systematic reviews. Literature retrieval strategy Following the 6S evidence hierarchy model, literature retrieval was conducted using a top-down approach, beginning with the highest level of evidence sources. This process included searching for guidelines, professional association websites, computer-based clinical decision-support systems, evidence-based practice databases, and comprehensive research databases. The data resources retrieved include the Guidelines International Network (GIN), Scottish Intercollegiate Guidelines Network (SIGN), Australian Clinical Practice Guidelines (ACPG), National Institute for Health and Care Excellence (NICE), The New Zealand Guidelines Group (NZGG), National Health and Medical Research Council (NHMRC), National Guideline Clearinghouse (NGC), National Comprehensive Cancer Network (NCCN), American Society of Clinical Oncology (ASCO), European Society for Medical Oncology (ESMO), Registered Nurses Association of Ontario (RNAO), Canadian Medical Association CPG Infobase (CMA INFOBASE), Cancer Care Ontario (CCO), Society for Immunotherapy of Cancer (SITC), Multinational Association of Supportive Care in Cancer (MASCC), World Health Organization (WHO) website, Medlive Guidelines Network, MedSci website, China Medical Knowledge Base, UpToDate, BMJ Best Practice, Cochrane Library, PubMed, Embase, CINAHL, SinoMed, CNKI, Wanfang, and VIP Database. The search covered publications from the inception of each database until November 5th, 2025. PubMed was used as a primary example of an English-language database, and the detailed search strategy is illustrated in Fig. 1 . The complete retrieval strategy is attached in Supplementary File 1 . Fig. 1. Open in a new tab English search strategy (PubMed as an example). Inclusion and exclusion criteria for literature Our inclusion and exclusion criteria are based on clinical questions of interest based on the evidence developed and defined by the PIPOST model, and are supplemented and refined on a subsequent basis. The inclusion criteria were established as follows: (i) Participants: aged 18 years or older who are currently receiving or have previously received ICIs; (ii) Intervention: nursing-related aspects of cirAEs (prevention, assessment/monitoring, grading, symptom management, patient education, and follow-up) (iii) Outcomes: cirAEs-related patient outcomes (e.g., incidence after nursing interventions, symptom remission/alleviation, psychosocial impact, cirAE-related quality of life); and/or nurse-level outcomes relevant to cirAEs care (e.g., knowledge or performance); (iv) Language: Publications in English or Chinese; (v) Evidence types: Study types including guidelines, evidence summaries, clinical decision-making resources, expert consensuses, and systematic reviews. In this evidence summary, cirAEs were operationally defined as immune-related inflammatory toxicities involving skin and/or mucosa that are clinically attributed to ICIs, with diagnosis/description aligned with CTCAE v5.0 or guideline-based definitions. Manifestations could include, but were not limited to, maculopapular rash, pruritus, lichenoid dermatitis, psoriasis-like dermatitis, vitiligo/hypopigmentation, bullous pemphigoid, severe cutaneous adverse reactions (SJS/TEN), and oral/mucosal lesions. The exclusion criteria are as follows: (i) skin or mucosal events clearly attributable to non-ICI causes (e.g., infection, radiotherapy/chemotherapy toxicity, or concomitant medications known to induce dermatologic complications) without a defensible link to ICIs; (ii) Studies involving individuals receiving concurrent medications known to cause skin-related complications; (iii) Duplicate publications; (iv) Studies with incomplete data or unclear outcome measures; (v) Translations, interpretative versions, or updated editions of previously published studies; (vi) Literature for which the full text was unavailable. Literature screening Literature screening was conducted using EndNote X9 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. 32 Two independent researchers with expertise in evidence-based nursing reviewed article titles and abstracts to identify studies for full-text analysis. Selected studies were further assessed based on the inclusion and exclusion criteria. References cited in the included studies were manually reviewed to identify additional relevant literature. The two researchers independently evaluated the quality of selected studies. Any discrepancies were resolved through discussion. If consensus could not be reached, a senior expert was consulted for a final decision. Priority was given to high-quality, recently published evidence. Quality assessment of included literature Assessment of guidelines Guidelines were appraised using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument, 33 which includes six domains comprising 23 items. Each item was scored on a scale from 1 to 7, with higher scores indicating better adherence to methodological standards. The final score for each domain is expressed as a standardized percentage, with higher percentages indicating superior guideline quality. The standardized percentage for a domain is calculated as (actual score for the domain - lowest possible score) / (highest possible score - lowest possible score). Guidelines scoring ≥ 60% across all six domains are classified as Grade A and recommended for use. Guidelines scoring between 30% and 60% in at least three domains, with at least one domain below 60%, are classified as Grade B and recommended with modifications. Guidelines scoring < 30% in at least three domains are classified as Grade C and not recommended. Only Grade A and Grade B guidelines were included in the final evidence synthesis. Inter-rater reliability was assessed using the intraclass correlation coefficient (ICC), with values greater than 0.75 indicating good agreement. 34 Assessment of systematic reviews Systematic reviews were assessed using the JBI methodological quality assessment tool, 35 which consists of 11 criteria. Each item was categorized as “yes”, “no”, “unclear”, or “not applicable”. The inclusion of a study was determined by evaluating the source of the literature, expert credibility, strength of the conclusions, and consistency with previous research. Studies were excluded if they had more than four items rated as “no”. 36 Assessment of expert consensus Expert consensuses were evaluated using the JBI Center for Evidence-Based Healthcare criteria, 37 which include six items rated as “yes,” “no,” “unclear,” or “not applicable.” The same assessment principles applied to systematic reviews were used to determine whether a consensus statement was included. Expert consensus documents with more than two “no” responses were excluded. 36 Assessment of evidence summaries and clinical decision-making resources For evidence summaries and clinical decision-making resources, the original source literature cited within them was traced back. The quality of these original studies was then appraised using tools appropriate to their study design (e.g., JBI critical appraisal checklists for RCTs or cohort studies, AGREE II for guidelines if applicable). Evidence extraction and synthesis Two independent researchers extracted relevant data from the included literature. Extracted information included the study author, title, publication year, evidence source, study type, and nursing recommendations related to cirAEs. Any discrepancies were resolved through discussion, with a third reviewer consulted when necessary. The extracted recommendations were translated, analyzed, and synthesized. The summarized evidence was graded and recommended by the 2014 JBI evidence pre-grading and evidence recommendation level system, which ranks evidence from Level 1 (highest) to Level 5 (lowest). 38 When inconsistencies arose, discussions were held, and unresolved issues were referred to a third reviewer. The principles for evidence synthesis are as follows: 1) When recommendations are similar, the most concise and clearly stated version is selected; 2) When recommendations are complementary, they are integrated based on logical relationships; 3) When recommendations conflict, priority is given to evidence-based sources, high-quality studies, and the most recent findings. Lower-level evidence (e.g., regional expert consensus) should not override higher-level evidence (e.g., systematic reviews or international guidelines). Six clinical experts were invited to evaluate the feasibility, appropriateness, meaningfulness, and effectiveness of the synthesized evidence. For each attribute, a ‘yes’ response was scored as 1 point and a ‘no’ as 0 points, yielding a total score ranging from 0 to 4 per recommendation. Experts also discussed the strength of evidence recommendations, which were categorized as either strong (Grade A) or weak (Grade B). Detailed evaluation criteria are presented in Table 1 . A recommendation was rated as Grade A if each of the indicated standards were present. Otherwise, it is recommended as Grade B. For mixed findings, consensus discussion was used to determine final grade. Table 1. Criteria for evidence recommendation levels. Recommended level Standard of judgment Grade A: Strong recommendation 1. The intervention clearly demonstrates more benefits than harms or more harms than benefits 2. High-quality evidence supports its use 3. It is favorable or has no impact on resource allocation 4. It considers patients' values, preferences, and experiences Grade B: Weak recommendation 1. The intervention demonstrates more benefits than harms or more harms than benefits, despite the uncertainty in the evidence 2. Evidence supports its use, despite the low quality of evidence 3. It is favorable or has minimal impact on resource allocation 4. It partially considers or does not consider patients' values, preferences, and experiences Open in a new tab Results Evidence retrieval results and characteristics of included literature The initial search yielded 1894 articles, including 198 from guidelines and professional association websites, 580 from computer-based decision-making systems and evidence-based databases, and 1116 from comprehensive research databases. After screening by two independent researchers, 24 articles were selected for inclusion. 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 These comprised 7 guidelines, 20 , 21 , 22 , 23 , 39 , 40 , 41 3 systematic reviews, 44 , 45 , 46 9 expert consensuses, 24 , 25 , 47 , 48 , 49 , 50 , 51 , 52 , 53 2 clinical decisions, 42 , 43 and 3 evidence summaries. 26 , 27 , 28 The literature screening process is depicted in Fig. 2 . The characteristics of the included literature are summarized in Table 2 . Fig. 2. Open in a new tab Flow diagram illustrating the original process of screening and identification of studies. GIN, Guidelines International Network; NICE, National Institute for Health and Care Excellence; NGC, National Guideline Clearinghouse; NCCN, National Comprehensive Cancer Network; ASCO, American Society of Clinical Oncology; ESMO, European Society for Medical Oncology; CCO, Cancer Care Ontario; SITC, Society for Immunotherapy of Cancer; MASCC, Multinational Association of Supportive Care in Cancer; WHO, World Health Organization website; CNKI, China National Knowledge Infrastructure. Table 2. Basic characteristics of the included literature ( n = 24). Included literature Year of publication (year) Source of evidence Type of literature Literature topics Haanen, et al. 20 2022 ESMO Guideline Management of dermatologic toxicities related to ICIs Apalla et al. 21 2022 PubMed Guideline Management of ICIs-derived dermatologic adverse events Schneider et al. 22 2021 ASCO Guideline Management of irAEs Chinese Society of clinical Oncology 23 2023 CSCO Guideline Management of ICI-related toxicity Brahmer et al. 39 2021 SITC Guideline Management of ICI-related adverse events Forbes et al. 40 2018 CCO Guideline ICIs toxicity management National Comprehensive Cancer Network 41 2025 NCCN Guideline Management of immunotherapy-related toxicities Postow et al. 42 2024 UpToDate Clinical decision Management of ICI-related toxicity Patel 43 2024 UpToDate Clinical decision Management of cirAEs Hao et al. 26 2024 CNKI Summary of evidence Management of cirAEs Xu et al. 27 2022 CNKI Summary of evidence Management of Secondary pruritus in cancer patients with Anti-PD-1/PD-L1 therapy Zheng et al. 28 2023 CNKI Summary of evidence Prevention and nursing of ICI-associated skin toxicity in lung cancer patients Garrett et al. 44 2020 PubMed Systematic review cirAEs in lung cancer patients Nadelmann et al. 45 2022 PubMed Systematic review Management of cirAEs Simonsen et al. 46 2020 PubMed Systematic review Cutaneous adverse reactions to anti-PD-1 treatment Niu et al. 24 2021 CNKI Expert consensus Management of adverse reactions related to ICIs Sun et al. 25 2025 CNKI Expert consensus Management of cirAEs Shanghai Society of Dermatology and Venereology et al. 47 2023 Medlive Expert consensus Management of cutaneous adverse reactions to anti⁃tumor drugs Wang et al. 48 2024 Wanfang Expert consensus Nursing care for ICI-related adverse reactions in esophageal cancer patients Expert Committee on Anti-tumor drug safety management of Chinese Society of clinical oncology et al. 49 2020 CNKI Expert consensus Clinical diagnosis and treatment of camrelizumab induced reactive cutaneous capillary endothelial proliferation Immunotherapy expert Committee of Chinese Society of clinical Oncology 50 2022 CNKI Expert consensus Application of immune checkpoint inhibitors in special populations CMAMTDaTP Committee et al. 51 2022 Medlive Expert consensus Prevention and management of toxicity related to ICIs Choi et al. 52 2020 PubMed Expert consensus Management of severe dermatological toxicities from ICIs Thebeau et al. 53 2017 CINAHL Expert consensus Management of skin adverse events associated with ICIs in patients with melanoma Open in a new tab ESMO, European Society for Medical Oncology; ASCO, American Society of Clinical Oncology; CSCO, Chinese Society of Clinical Oncology; SITC, Society for Immunotherapy of Cancer; CCO, Cancer Care Ontario; NCCN, National Comprehensive Cancer Network; CNKI, China National Knowledge Infrastructure; ICIs, Immune Checkpoint Inhibitors; irAEs, immunotherapy-related Adverse Events; cirAEs, cutaneous immune-related Adverse Events; PD-1/PD-L1: programmed cell death-1/ligand 1. Quality assessment of included literature Guidelines A total of seven guidelines were included in the study. 20 , 21 , 22 , 23 , 39 , 40 , 41 The ICC between the two researchers exceeded 0.75, indicating strong inter-rater reliability. Based on this consistency, all selected guidelines were approved for inclusion. The standardized percentages for each domain of the AGREE II instrument are presented in Supplementary File 2 . Systematic reviews Three systematic reviews were included. 44 , 45 , 46 In the studies by Nadelmann et al., 45 and Simonsen et al., 46 all assessment criteria were rated as “yes” except for item 5, which evaluated the appropriateness of quality assessment criteria and was rated as “unclear”, and item 8, which assessed the suitability of methods used to combine studies and was marked as “not applicable”. In Garrett et al.’s study all items were rated as “yes”. 44 Given their well-designed methodologies and high quality, all three systematic reviews were approved for inclusion. The quality evaluation results of the systematic reviews are shown in Supplementary File 2 . Expert consensuses Nine statements were included in the study. 24 , 25 , 47 , 48 , 49 , 50 , 51 , 52 , 53 In the consensus documents by Niu et al., 24 Sun et al., 25 and Thebeau et al., 53 all items were rated as “yes” except for item 2, which assessed whether the opinions were sourced from influential experts in the field and was marked as “unclear”, and item 6, which evaluated consistency with previous literature and was marked as “no.” In the remaining six consensus statements, 47 , 48 , 49 , 50 , 51 , 52 all items except for item 6, which was similarly rated as “no”, were rated as “yes”. Given their rigorous development process and overall high quality, all nine expert consensuses were approved for inclusion. The quality evaluation results of the expert consensuses are presented in Supplementary File 2 . Clinical decision reports and evidence summaries The study included two clinical decision reports, 42 , 43 and three evidence summaries. 26 , 27 , 28 These sources led to the identification of 14 original studies, all of which had already been included in the literature selection process. Evidence integration and synthesis Following a comprehensive synthesis of the included evidence, and guided by established clinical management principles for irAEs adapted to the nursing context, 54 we organized the recommendations into five core domains: prevention, assessment, grading, nursing interventions, and patient education and follow-up. A summary was then developed with careful consideration of clinical feasibility, appropriateness, significance, and effectiveness. The final evidence synthesis identified 25 key recommendations across these domains. Each recommendation was graded based on the strength of the supporting evidence, and corresponding recommendations were formulated, as detailed in Table 3 . The detailed FAME scores assigned by the six clinical experts to each recommendation are provided in Supplementary File 3 . Table 3. Summary of best evidence for nursing of cirAEs in patients with cancer. Theme Evidence content ICI types cirAEs manifestations Level Recommendation Prevention 1. Use a mild (pH = 7) cleanser for bathing, select an appropriate shampoo and conditioner, avoid prolonged bathing, and maintain water temperature at ≤ 40°C. 21 , 28 , 40 , 47 , 48 ICIs (PD-1/PD-L1/CTLA-4) All types 2c A 2. Apply a moisturizer containing glycerin or 5%–10% urea to the skin for hydration. 21 , 28 , 47 ICIs (PD-1/PD-L1/CTLA-4) All types 2c B 3. Use a fragrance-free and non-irritating sunscreen (SP F ≥ 30, PA ≥ ++) to reduce UV exposure. 21 , 28 , 47 ICIs (PD-1/PD-L1/CTLA-4) All types 2c A 4. Maintain good oral hygiene, consume light, easily digestible, and nutritious food, and limit caffeine intake. 48 ICIs (PD-1/PD-L1/CTLA-4) All types 3d A Assessment 5. Time of assessment: Upon admission, before and after medication. 23 , 48 , 55 ICIs (PD-1/PD-L1/CTLA-4) All types 5b A 6. Assessment frequency: During treatment, assess the patient's general condition, skin, and mucous membranes during each ward round, and conduct hematological assessments every 2–3 weeks. 23 ICIs (PD-1/PD-L1/CTLA-4) All types 5b B 7. Assessment content: ① skin and mucous membranes : Check for damage, pigmentation, scars, etc., and take photos of abnormalities for record-keeping 20 , 24 , 46 , 48 , 53 ; ② high-risk factors: Demographic factors (excessive sun exposure, excessive skin cleansing, age > 65, smoking history, obesity or overweight); disease and treatment factors (baseline comorbidities, skin disease history, autoimmune disease history, family history of cancer, radiation therapy history, chemotherapy history, combination therapy, history of adverse reactions); Hematological indicators (low albumin levels, neutrophil-to-lymphocyte ratio < 3, prognostic nutritional index ≥ 45, platelet-to-lymphocyte ratio < 180, eosinophilia, low interleukin-6 levels) 28 , 44 , 50 , 51 ; ③ needs: Potential need for home care support. 41 PD-1/PD-L1 All types 1a A Grading 8. Tool: Use the “common Terminology criteria for adverse events (CTCAE 5.0)" for grading and description. 22 , 23 , 41 ICIs (PD-1/PD-L1/CTLA-4) All types 5b A 9. Grading of rash, reactive cutaneous capillary hyperplasia, alopecia: Grade 1: Rash < 10% body surface area (BSA), alopecia < 50% of normal, maximum hyperplastic nodule diameter ≤ 10 mm; grade 2: Rash 10%–30% BSA, alopecia > 50%, maximum hyperplastic nodule diameter > 10 mm; grade 3: Rash > 30% BSA; grade 4: Rash > 30% BSA with itching, burning sensation. 21 , 25 , 40 , 41 ICIs (PD-1/PD-L1/CTLA-4) Rash, reactive cutaneous capillary hyperplasia, alopecia 5b A 10. Itching grading: Grade 1: Mild or localized; grade 2: Intense or widespread, skin broken due to scratching; grade 3: Affects sleep. 43 , 45 ICIs (PD-1/PD-L1/CTLA-4) Itching 5b A 11. Grading of oral mucosal lesions: Grade 1: No significant changes; grade 2: White reticulated lesions in the mouth with moderate pain; grade 3: Lichenoid lesions in the mouth, severe pain, unable to eat. 21 ICIs (PD-1/PD-L1/CTLA-4) Oral mucosal lesions 5b A Nursing intervention 12. Multidisciplinary collaboration: For symptoms of grade 2 or higher, involve medical oncologists, nurses, and dermatologists in diagnosis and treatment. 22 , 52 , 53 ICIs (PD-1/PD-L1/CTLA-4) All types 5b A 13. Rash: ① grades 1–2: Apply potent topical steroids until symptoms are controlled for 15 days; ② grades 3–4: Stop immunotherapy, urgently consult dermatology, apply high-potency topical steroids, cover open wounds with petroleum jelly ointment and bandages, change dressings 1–2 times daily. 20 , 42 , 52 PD-1/PD-L1/CTLA-4 Rash 1a B 14. Reactive cutaneous capillary hyperplasia: First, protect friction-prone areas with gauze or band-aids. Then, for any bleeding, control it with local pressure followed by the application of a topical hemostatic powder (e.g., gelatin sponge powder, zinc oxide). Finally, apply mupirocin ointment to prevent infection. Suitable hemostatic materials should be selected according to local availability. 47 , 49 PD-1 (camrelizumab) Reactive cutaneous capillary hyperplasia 3d A 15. Itching: For rashes with itching, apply cold compresses and consider oral antihistamines or antipruritic drugs (e.g., diphenhydramine or hydroxyzine). 27 , 40 , 41 , 45 For patients with itching but no rash, consider topical antipruritic drugs (e.g., menthol and pramoxine). 22 , 28 PD-1/PD-L1 Itching 3b B 16. Alopecia and hypopigmentation (especially facial involvement): In addition to symptomatic treatment, provide psychological counseling and consider repair or camouflage if necessary. 23 , 47 PD-1/PD-L1/CTLA-4 Alopecia and hypopigmentation (especially facial involvement) 3c A 17. Oral mucosal lesions: ① Grades 1–2: Use high-potency topical steroids (dexamethasone 0.5 mg/5 mL or 0.05% fluocinonide) as an oral solution or gel; ②Grades 3–4: Use more potent steroid preparations (clobetasol 0.05%, budesonide 3 mg/10 mL). 21 , 43 ensure nutritional intake, stimulate saliva for dry mouth (sugar-free gum or candy stimulants, artificial saliva), lubricate lips, and use a mouthwash mixed with equal parts diphenhydramine, antacid, and viscous lidocaine for local anesthesia for painful areas. 21 PD-1/PD-L1/CTLA-4 Oral mucosal lesions 4c B 18. Nursing for immunosuppressive drug use: Regularly observe patients for symptoms such as hematemesis, melena, decreased appetite, and edema. Monitor blood pressure, fasting and postprandial blood glucose daily, and record 24-h urine output. 39 , 41 PD-1/PD-L1/CTLA-4 All types 5b B Patient education and follow-up 19. Pre-education assessment: Assess the patient's understanding level and ability to monitor and report potential adverse events. 26 PD-1/PD-L1/CTLA-4 All types 5b B 20. Time for education: Before, during, and after treatment. 22 , 27 , 39 , 48 PD-1/PD-L1 (ICIs) All types 5b A 21. Education content: ① for all patients: Mechanism of action of immunotherapy, prevention and reporting of potential adverse events, potential risks of corticosteroid use, and avenues for obtaining education; 26 , 48 ② for those with fertility/breastfeeding needs: Effective contraception during treatment and for 5 months afterward, and avoid breastfeeding. 39 , 41 PD-1/PD-L1/CTLA-4 All types 5b B 22. Education format: Information manuals or educational cards. 20 , 22 PD-1/PD-L1/CTLA-4 All types 5b B 23. Follow-up duration: At least 2 years after the end of immunotherapy. 41 PD-1/PD-L1/CTLA-4 All types 5b A 24. Follow-up frequency: ① during treatment: Each medication cycle; ② after treatment: Every 6–12 weeks. 23 PD-1/PD-L1/CTLA-4 All types 5b A 25. Follow-up content: General condition and skin examination, and skin biopsy if necessary. 51 PD-1/PD-L1/CTLA-4 All types 5b B Open in a new tab Evidence level was evaluated by the 2014 JBI evidence pre-grading and evidence recommendation level system, which ranks evidence from Level 1 (highest) to Level 5 (lowest). Evidence recommendations are assessed by the JBI system as strong recommendations (Grade A) or weak recommendations (Grade B). The evidence in Table 3 applies to pan-cancer populations receiving ICIs.. ICIs, immune checkpoint inhibitors; PD-1/PD-L1: programmed cell death-1/ligand 1; CTLA-4, cytotoxic T-lymphocyte associated antigen-4; JBI, Joanna Briggs Institute. Discussion Main findings This study focused on the nursing management of cirAEs for cancer patients receiving ICIs. Building upon existing evidence-based practices, it incorporates both Chinese and international literature to develop a comprehensive best-evidence set. The 25 included evidence items were categorized into five key domains: prevention, assessment, grading, nursing interventions, and patient education with follow-up. These domains provide a structured framework to guide clinical nursing practice across the entire care continuum for patients experiencing cirAEs. Among the 25 included items, 15 (60.0%) were rated as Grade A recommendations, reflecting a generally high level of clinical applicability and expert consensus. A few items, such as those involving moisturizer selection and certain follow-up protocols, were based on lower-level evidence (Levels 3 to 5) or received Grade B recommendations, suggesting the need for further high-quality research to strengthen clinical confidence and optimize nursing practice. Effective preventive skin care serves as the foundational safeguard for the nursing of cirAEs Evidence contents 1–4 summarize the preventive nursing measures for the skin and oral mucosa in patients undergoing immunotherapy. Among them, Evidence 1–3 emphasize the importance of skin cleansing, moisturizing, sun protection, and avoiding skin irritation in preventing skin symptoms. The relevant evidence is derived from high-quality quasi-experimental studies and provide clear clinical guidance. All patients receiving immunotherapy should engage in regular moisturizing, cleansing, and sun protection. Moisturizing lotions containing 5% to 10% urea are particularly effective in maintaining hydration, enhancing the skin barrier, and providing antibacterial and non-irritating benefits, making them a crucial component of cirAEs prevention. 56 Patients should use neutral soaps or body washes with a pH of 7 for cleansing. After bathing or when experiencing dryness, moisturizing lotion should be applied to reinforce the skin barrier function. 21 , 40 The selection of emollients should be tailored to patients’ individual preferences to improve adherence. Some patients may be reluctant to use emollients due to discomfort or disruptions to their sleep when applied at night. To address this, clinicians should recommend daytime application initially, gradually increasing usage frequency, and regularly assess adherence during hospital visits. Similarly, when advising patients on sunscreen use, fragrance-free and non-irritating formulations should be prioritized to minimize skin irritation. Evidence content 4 highlights the importance of preventive oral mucosal care. Upon initiating immunotherapy, healthcare providers should educate patients about the importance of daily oral hygiene, including regular brushing and the consumption of soft, nutritious foods to protect the oral mucosa. 48 Evidence suggests that preventive care measures for patients with cancer undergoing immunotherapy, including skin moisturizing, sun protection, and maintaining oral mucosal health, can significantly reduce cirAEs incidence, with one study reporting a decline from 31.71% to 11.90% ( P = 0.029). 57 Furthermore, oral mucositis, as a component of skin toxicity, can affect nutritional intake, particularly in patients experiencing cancer-related cachexia, emphasizing the necessity of appropriate dietary and oral care interventions. 48 Early and comprehensive assessment of high-risk populations and symptom onset is a crucial prerequisite for the nursing of cirAEs Evidence contents 5–7 focus on the assessment of cirAEs in patients with cancer. The assessment of cirAEs in patients undergoing immunotherapy should span the entire treatment cycle, beginning at admission and continuing through treatment and follow-up. Given the unpredictable onset and complex mechanisms of cirAEs, early symptom evaluation and risk assessment are crucial for timely intervention. Multiple sources of evidence indicate that a thorough skin and mucosal examination upon admission is crucial in determining their eligibility for immunotherapy. 20 , 24 , 46 , 48 , 53 Prior to initiating immunotherapy, high-risk populations for skin toxicity should be screened and assessed to enable early detection and management of potential complications. Currently, there is no standardized tool for assessing cirAEs risk. However, expert consensuses and systematic reviews suggest that factors such as prolonged sun exposure, 28 , 44 , 50 , 51 excessive skin cleansing, pre-existing skin conditions, comorbidities, low albumin levels, and a neutrophil-to-lymphocyte ratio < 3 are closely linked to cirAEs occurrence. These findings have high levels of evidence and provide valuable guidance. Long-term ultraviolet radiation exposure has been associated with a higher tumor mutation burden, increasing susceptibility to cirAEs during immunotherapy. 58 Excessive skin cleansing may also compromise the protective barrier, making the skin more vulnerable to immunotherapy-related reaction. 59 In clinical practice, nurses can select assessable factors based on the department's resources to determine the likelihood of cirAEs in patients. Additionally, patients with habits of excessive sun exposure and skin cleansing can be provided with corresponding interventions to reduce high-risk factors. Throughout treatment, healthcare providers should conduct routine skin and mucosal assessments during ward rounds. If abnormalities are found, their type and severity should be accurately recorded, including photographic documentation, to ensure continuity of care across nursing shifts. Accurate symptom grading as a prerequisite for effective cirAEs management Evidence contents 8–11 compile standardized grading tools for cirAEs. The "Common Terminology Criteria for Adverse Events 5.0" is the most widely used grading tool for cirAEs. 22 , 23 , 41 However, given the diverse range of symptoms, adjustments have been made in clinical practice to refine grading criteria. For conditions such as rash, the included studies recommend using body surface area (BSA) coverage thresholds of 10% and 30%, 21 , 25 , 40 , 41 a 50% reduction in normal hair growth, and a maximum nodule diameter of 10 mm as key benchmarks. The highest severity grade, Grade 4, indicates significant impairment of daily life, often accompanied by multiple related symptoms. Since grading severity is closely linked to BSA involvement or lesion size, healthcare providers can utilize measurement techniques such as the 9-point rule or palm-size estimation for greater accuracy. For symptoms like pruritus and oral mucosal lesions, included guidelines suggest that grading should reflect their impact on daily activities. 21 , 60 Clinical guidelines suggest that if a patient experiences significant sleep disruption or difficulty eating due to cirAEs, the symptoms should be classified as severe and promptly reported for further management. 21 , 43 , 45 Targeted interventions for effective cirAEs management Evidence contents 12–19 provide guidance on nursing interventions for cirAEs. Evidence 12 emphasizes the importance of a multidisciplinary approach in symptom management and nursing interventions for cirAEs, with specific requirements for practicing nurses. Given the challenges of managing cirAEs symptoms, basic interventions by the conventional oncology healthcare team alone cannot fully guarantee symptom recovery or improvement. The ASCO guidelines highlight that multidisciplinary, 22 interprofessional, and tiered interventions are crucial for cirAEs. For patients experiencing Grade 2 or higher symptoms, early involvement of dermatologists is essential to prevent disease progression. 22 , 52 , 53 Evidence contents 13–16 discuss nursing interventions for cutaneous symptoms. Nursing interventions should be tailored based on symptom type, severity, and the presence of complications. For mild cases, localized interventions can effectively alleviate symptoms. For instance, potent topical steroids should be applied using gentle circular motions for rashes, pressure application can be used for localized hemorrhage, and iced menthol can be administered to relieve itching. Evidence 16 suggests that for alopecia and hypopigmentation, which primarily affect the head and face, psychological distress is a major concern. Healthcare providers should offer psychological support to address patients' emotional well-being. Evidence content 17 highlights the key aspects of intervention and supportive care for oral mucositis. Oral mucositis, a common cirAEs, requires corticosteroid-based interventions, with different formulations selected depending on severity. Due to associated dietary restrictions, nutritional assessment and dietary adjustments are crucial to maintaining adequate nutrient intake. For patients experiencing pain, anesthetic mouthwashes can provide relief, 21 while those with dry mouth may benefit from saliva-stimulating measures, 21 , 61 such as sugar-free gum, increased hydration, regular nasal cavity cleansing, and lip lubrication. Evidence contents 18 pertains to medication-related nursing for patients using glucocorticoids. For patients requiring systemic glucocorticoid therapy due to severe skin and mucosal ulcerations, local interventions alone may be insufficient. In such cases, nurses play a critical role in ensuring safe and effective treatment delivery under the physician's prescription. Key nursing responsibilities include: accurately implementing the prescribed medication regimen; educating patients on proper administration techniques; vigilantly monitoring treatment response and potential side effects (such as hematemesis, melena, and fluid/electrolyte imbalance); and promptly reporting any concerns to the healthcare team. This comprehensive supportive care is essential to monitor medication safety and prevent complications. These findings underscore the importance of individualized nursing interventions for patients with cirAEs, adjusted according to symptom severity, associated complications, and psychological well-being. The ultimate goal is to alleviate discomfort and enhance patients' quality of life. Comprehensive patient education and follow-up as pillars of cirAEs management Evidence contents 19–25 cover patient health education and follow-up. Specifically, evidence contents 19–22 indicate that patient education should encompass pre-education assessment, timing, content, and format. Patient health education and follow-up contribute to enhancing patients' understanding of their disease and treatment, improving their comprehension and cooperation with nursing measures, effectively preventing and managing cutaneous adverse events, enhancing the quality of nursing care, and ensuring patient safety. Effective education strategies should be tailored to patients’ comprehension levels, ensuring they can accurately recognize, monitor, and report adverse events, so that patients can correctly implement it. 26 For patients with limitations in receiving and implementing education, a responsive caregiver should be selected to accompany them and receive health education jointly with the patient. Evidence suggests that using educational materials such as knowledge handbooks or informational cards improves patient understanding and use. 20 , 22 Evidence contents 23–25 pertain to follow-up. Due to the delayed onset of cirAEs, which can occur up to 12 months or longer post-treatment, 62 the guidelines recommend that follow-up continue for at least 2 years after treatment completion, 41 with frequency adjusted according to each patient's disease status; thus, clinical nurses need to be aware of the patient's treatment phase and choose appropriate follow-up timings. The healthcare team should increase the frequency of follow-up and conduct thorough assessments during follow-up, 41 inquiring about recent symptoms and performing physical examinations. A recent clinical study by Chen et al. 63 indicated that a self-reported outcome manual is highly effective in facilitating symptom monitoring during follow-up. Healthcare providers should incorporate such tools to enhance follow-up efficiency, ensure timely intervention, and improve overall patient outcomes. Implications for nursing practice and research The management of cirAEs remains a complex and demanding aspect of oncology nursing. This study compiled 25 key pieces of evidence to guide the nursing care of patients with cancer experiencing cirAEs, spanning prevention, assessment, grading, symptom management, health education, and follow-up. It provides a comprehensive range of systematic nursing measures for patients from the time of patient admission. This compilation of 25 evidence-based recommendations provides a structured guide for nurses in the prevention, assessment, and management of cirAEs. Adherence to such evidence-informed practice is expected to contribute to improved patient outcomes. Throughout the nursing process, effective preventive skin care serves as the foundational guarantee for cirAEs nursing, while timely and thorough assessment of high-risk populations and symptom onset is critical for early intervention. This study serves as a valuable resource for oncology nurses worldwide, in terms of practical guidance to enhance the quality of care for patients with cancer undergoing immunotherapy. Limitations While this study provides a comprehensive synthesis of the best available evidence for the nursing care of cirAEs in patients with cancer, certain limitations should be acknowledged. First, the study includes only literature published in Chinese and English, which may limit the breadth of the results. Research primarily based on Chinese-language databases may also limit its generalizability to non-Chinese contexts, despite enhancing understanding of care strategies for Chinese patients. Second, some of the included evidence originates from international sources, and differences in language and cultural contexts may create discrepancies between the evidence and clinical practice. Therefore, future research should incorporate globally accessible alternatives to enhance the global representativeness and cross-cultural applicability of its conclusions. What's more, this study focused on patient- and nurse-level outcomes relevant to nursing practice. Outcomes at the provider or system level were beyond the scope of this evidence summary but are worth exploring in future implementation research. Conclusions Conducted as a best evidence summary following established evidence-based methodologies, this study systematically reviews and summarizes the best available evidence from Chinese and English literature for the nursing care of patients with cirAEs, covering five key domains: prevention, assessment, grading, symptom management, health education, and follow-up. The evidence has been rigorously reviewed by experts specializing in irAEs nursing and offers a robust foundation for evidence-based recommendations in clinical oncology nursing. In future, evidence-based practice needs to integrate clinical scenarios and patient preferences while identifying facilitators and barriers to its adoption. Moreover, continuous screening of evidence entries and assessment of their practical feasibility, suitability, clinical significance, and effectiveness are crucial. CRediT authorship contribution statement Su Zhenzhen: Conceptualization, Methodology, Data curation, Formal analysis, Writing - original draft, Writing - review & editing. Shuyu Han: Conceptualization, Methodology, Writing - review & editing, Supervision, Project administration. Zhang Liyan: Conceptualization, Methodology, Data curation, Resources, Writing - review & editing, Supervision, Project administration, Funding acquisition. Lian Xuemin: Writing - Review & Editing, Formal analysis. Wang Yixuan: Writing - Review & Editing, Formal analysis. Liu Dan: Formal analysis. All authors read and approved the final manuscript. All authors have read and approved the final manuscript. Ethics statement Not required. Data availability statement All data generated or analyzed during this study are included in this published article and its supplementary materials. Declaration of generative AI and AI-assisted technologies in the writing process No AI tools/services were used during the preparation of this work. Funding This work was supported by grants from the Peking University Health Science Center Evidence-based Nursing Research Fund (Grant No. XZJJ-2024-12) for funding. The funders had no role in considering the study design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication. Declaration of competing interest The authors have no conflicts of interest to declare. Footnotes Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.apjon.2026.100943 . Appendix A. Supplementary data The following are the Supplementary data to this article: Multimedia component 1 mmc1.docx (36.5KB, docx) Multimedia component 2 mmc2.docx (64.7KB, docx) Multimedia component 3 mmc3.docx (165.9KB, docx) References 1. Lu Q., Kou D., Lou S., et al. 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Supplementary Materials Multimedia component 1 mmc1.docx (36.5KB, docx) Multimedia component 2 mmc2.docx (64.7KB, docx) Multimedia component 3 mmc3.docx (165.9KB, docx) Data Availability Statement All data generated or analyzed during this study are included in this published article and its supplementary materials. 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